Hoffa's Fat Pad - Knee Injury Advice
otleyboy Posts: 2
in General Chat
Completed 1st long distance in July this year (Roth, Germany), all went very well however have been suffering from pain in left knee since. Have had an MRI scan, and Sports Doc. confirms that I've a horizontal tear in the Hoffa's Fat Pad located below the knee cap. There is no impingement, and no swelling, otherwise knee is good. Doc advises rest, and I now have a knee support with silicon ring at kneecap to provide massage effect whilst wearing. Question - has anyone experienced same injury? Is there any treatment other than rest? Are there any specific exercises that are recommended to speed and aid recovery? I can now jog without pain, but it is certainly not 100%. Any advice or experience from anyone?
You have my sympathy with the knee injury,I have acl and mcl damage along with a mal tracking knee cap ,but have managed to work around it and not go in for surgery by strengthening the support muscles and exercising through the Egoscue Method (various dvds and books on the subject).
your injury sounds interesting in that most fat pad problems I treat are due to impingement or irritation. This is usually easily diagnosed by getting the patient to fully extend (straighten)their knee whilst the examiner pushes with his thumbs either side of the patella tendon ( thick band that extends from the bottom of the knee cap into the tibia). It is interesting that the MRI shows a tear but you say there is no impingement ?, often tears particularly in tendons are the end product of irritation . If there was a history of trauma eg a fall directly on the knee that could explain why there is just a tear in the fat pad, however if the symptoms have gradually come on then it is likely there is some biomechanical problem which should be addressed as Jon E has pointed out.
As well as rest, the things I would be looking at in a triathlete who complained of a fat pad problem which had gradually occurred would be do their knees hyper extend, have they got tight hip flexors( very common with fat pad problems ), also any other muscle length descrepencies particularly calves, hamstrings and the iliotibial band and muscle weakness ( particularly around the hip ).
Bike set up could be a factor, if the knee is fully straight or hyper extending when the pedal is at the bottom of the crank, then the fatpad will be in a compromised position, this can be rectified by slightly lowering your seat,( so that the knee is not completelystraight ) .However dont lower too much as this could cause other problems like patella tendinitis.
In order to stop the athlete going crazy I would suggest they practise swimming with a float buoy between their thighs so that the knee can rest without kicking, provided there was no pain during or after that activity I would be happy for them to do this as much as they liked.
It probably would pay to see a physiotherapist who could identify an biomechanical problems which you could work on until the knee is completely healed.
V taping in which tape is applied in a v with the appex under the bottom of the knee and ending oneach side of the thigh, or taping horizontally over the upper portion of the knee cap, is useful in off loading the fat pad when run and cycle training is deemed safe to commence.
Good luck and good recovery
many thanks for detailed and informative reply. I share your scepticsim, and I am glad that you have highlighted your concerns. The MRI report specifically states that there is no impingement, simply a horizontal tear in the Fat Pad. It concludes that the most likely caus eof the injury is a trauma impact to the knee cap. The problem, as I have explained to the sports doc. (not the same clinic who did the MRI and wrote the report), is that I have not have any trauma injury to the knee cap, at least not in the last 8 years since I stopped playing rugby.
I've never had knee problems, and up to and during the Long Distance, I had no problems at all. No pain, and no discomfort. When I started light jogging approx 1 week after Roth (with hindsight too soon), I had slight knee pain, but not extreme. I ran a 10 km 3 weeks after Roth, after which my knee was painful when I ran. The discomfort (probably not enough to describe as pain), is mostly on the left inner lower side of the left knee, to the side of the knee cap, but the discomfort can also localise to the top of the knee cap in the center when I sit. Swimming and cycling is no problem, I can feel the knee is not 100%, but it is in no way uncomfortable or painful.
I've googled everything to do with Hoffa's Fat Pad injury, but I cannot find any evidence that a tear in the Fat Pad can occur simply from overuse during a long distance event. I've also thought about the bike set-up, and possible over-extention, however I cycled 5000km on the bike during Roth prep training, including several 150km + rides, without any problem.
The weather at Roth was cold (13 deg C), and wet, maybe the cold simply got into the joint, but this would not have torn the Fat Pad.
I have now rested the knee, no running, for 4 weeks, and do not have the feeling that it is really much better. I have a flexible knee bandage/brace that I wear now, recommended by sports doc., but am not convinced that it is doing much.
Is it possible that the fat pad is impinged, but it was not spotted on the MRI? The report stated specifically that there was no impingement. Is it sometimes difficult to see accurately?
Any additional advice, comments or thoughts would be very greatly received.
Considering the MRI would have been done whilst you were resting ( and probably not experiencing the pain) I would say from a physiotherapeutic point of view it could be quite likely that the fat pad was not impinged when the MRI was done. When you are running due to muscle activity around the knee cap ( eg the pull of your quadriceps) the picture maybe quite different.
From my experience fat pad irritation/ inflammation usually shows up on MRI as edema (swelling ) and is enlarged, if this has not appeared this maybe what the radiologist is getting at when they say there is no evidence of impingement, the only other thing that I can think that they maybe using to determine impingement is the proximity of the bottom of the knee cap to the fat pad, however as I have previously said the position of the knee cap whilst having an MRI is quite different to when running.
Where you describe you are feeling the pain I would consider the possibility that patella femoral dysfunction ( maltracking of the knee cap) maybe contributing, this is not uncommon in long distance events where the body has fatigued and muscles stop doing what they are supposed to. It is also sometimes very hard to identify on MRI.
This is how I would differentiate the two in order to find out what is contributing mostly to your pain.
A fat pad problem would hurt more when running down hills ( due to increased extension of the knee ) and would hurt less when running up due to increased flexion.
A patella femoral problem would hurt more when running up hills and may also hurt when going down. Going up or down stairs would also be uncomfortable .
The other possibility could be you have an inflamed plica (usually can be felt as a small band of tightness where you have the pain on the inside of knee) these sometimes can be missed on MRI, and if do not settle can be easily removed using key hole surgery.
As you can see the knee is quite complex, however most conditions which appear to be due to overuse can be sorted with good biomechanical correction.
So I would book into see a physio who understands biomechanics and get a corrective programme, if it is just a tear of the fat pad biomechanical correction will not be detrimental and will serve a more rapid recovery.
Good luck and happy rehab
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